J.H. Holstein

Das komplexe Beckentrauma des älteren Patienten

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients >60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients >60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients >60 years of age was found to be significantly higher than in individuals <60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p <0.05, respectively).

Complex pelvic trauma in elderly patients

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients >60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients >60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients >60 years of age was found to be significantly higher than in individuals <60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p <0.05, respectively).

Anterior approaches to the pelvic ring

Anterior approaches for the stabilization of anterior and also posterior B and C type instability of the pelvic ring were the standard procedures before minimally invasive percutaneous methods supported by image intensifiers or navigation devices were established. Anterior approaches are currently still of high relevance for difficult or impossible closed reductions in multiple trauma surgery where the patient must remain in a supine position. They are also used for stabilization of an increasing number of osteoporotic fractures in the elderly which are no longer only treated in specialized pelvic trauma centres. The anterior as well as the posterior part of the pelvic ring can be stabilized via various anterior approaches. A Pfannenstiel incision is appropriate for plating of ruptures of the pubic symphysis and can be extended to a modified Stoppa approach if necessary. Fractures of the iliac wings can be approached either laterally or less traumatically, via an anterolateral approach. The latter equates the lateral window of the ilioinguinal approach to the acetabulum, allows visualization of the entire sacroiliac joint and therefore stabilization of not only iliosacral luxation but also luxated fractures with a small iliac fragment. By a combination of the different approaches it is possible to simultaneously stabilize ventral and dorsal instabilities in type C fractures of the pelvic ring with a minimal amount of iatrogenic soft tissue trauma. Although the described anterior approaches are considered as simple exact knowledge of the endangered structures and general risks for each approach are essential for a safe exposure of the anatomical region addressed.

Anteriore Zugänge zum Beckenring

Anterior approaches for the stabilization of anterior and also posterior B and C type instability of the pelvic ring were the standard procedures before minimally invasive percutaneous methods supported by image intensifiers or navigation devices were established. Anterior approaches are currently still of high relevance for difficult or impossible closed reductions in multiple trauma surgery where the patient must remain in a supine position. They are also used for stabilization of an increasing number of osteoporotic fractures in the elderly which are no longer only treated in specialized pelvic trauma centres. The anterior as well as the posterior part of the pelvic ring can be stabilized via various anterior approaches. A Pfannenstiel incision is appropriate for plating of ruptures of the pubic symphysis and can be extended to a modified Stoppa approach if necessary. Fractures of the iliac wings can be approached either laterally or less traumatically, via an anterolateral approach. The latter equates the lateral window of the ilioinguinal approach to the acetabulum, allows visualization of the entire sacroiliac joint and therefore stabilization of not only iliosacral luxation but also luxated fractures with a small iliac fragment. By a combination of the different approaches it is possible to simultaneously stabilize ventral and dorsal instabilities in type C fractures of the pelvic ring with a minimal amount of iatrogenic soft tissue trauma. Although the described anterior approaches are considered as simple exact knowledge of the endangered structures and general risks for each approach are essential for a safe exposure of the anatomical region addressed.

Anteriore Zugänge zum Beckenring@@@Anterior approaches to the pelvic ring

Anterior approaches for the stabilization of anterior and also posterior B and C type instability of the pelvic ring were the standard procedures before minimally invasive percutaneous methods supported by image intensifiers or navigation devices were established. Anterior approaches are currently still of high relevance for difficult or impossible closed reductions in multiple trauma surgery where the patient must remain in a supine position. They are also used for stabilization of an increasing number of osteoporotic fractures in the elderly which are no longer only treated in specialized pelvic trauma centres. The anterior as well as the posterior part of the pelvic ring can be stabilized via various anterior approaches. A Pfannenstiel incision is appropriate for plating of ruptures of the pubic symphysis and can be extended to a modified Stoppa approach if necessary. Fractures of the iliac wings can be approached either laterally or less traumatically, via an anterolateral approach. The latter equates the lateral window of the ilioinguinal approach to the acetabulum, allows visualization of the entire sacroiliac joint and therefore stabilization of not only iliosacral luxation but also luxated fractures with a small iliac fragment. By a combination of the different approaches it is possible to simultaneously stabilize ventral and dorsal instabilities in type C fractures of the pelvic ring with a minimal amount of iatrogenic soft tissue trauma. Although the described anterior approaches are considered as simple exact knowledge of the endangered structures and general risks for each approach are essential for a safe exposure of the anatomical region addressed.

Das komplexe Beckentrauma des älteren Patienten@@@Complex pelvic trauma in elderly patients

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients >60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients >60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients >60 years of age was found to be significantly higher than in individuals <60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p <0.05, respectively).